THERAPIST FACTORS
There are a number of
therapist qualities, some of which are discussed further in Chapters 14 and 15,
that appear to contribute to the success of this treatment. The ability to be active is
important and is a corner-stone of structural
therapy in general. Passive, reflective styles usually do not work well. The therapist must be able to be
supportive, concerned, accessible, and enthusiastic. A lack
of rigidity is also needed, as drug addicts' families are very skillful and
will t rip up" an inflexible therapist. Finally, the more a therapist is able
to tap into his own creative and intuitive potential, the more likely
he will be able to devise interventions that are both appropriate
to the situation and
effective.
In addition, the therapist
needs to be skilled in identifying family
and intersystem cycles and sequences. He has to
be able to observe what is happening in a family, or within a set of
systems, and document it. He also needs to know when to enter the cycle, based in part on the steps within it during which he has
the most leverage. For example (as implied
earlier), it might not be auspicious for him to try to break a cycle in
which, at the moment, the addict is hospitalized to detoxify from heroin—espeically if the therapist has no control over the detoxification process. More prudently, he
should wait until the addict returns
home and the family system has a more direct influence.
Therapeutic acumen of the above sort is not easy
to develop. It requires sharply honed observational skills and the ability to
selectively ignore the content of family
verbalizations. Attention is best directed toward the consequences of particular acts. Even
experienced thera-pists can sometimes become misled by red herring
behaviors and overlook the essential elements in a cycle. At
the very least, however, this approach requires a different perspective of the addiction process and the people and systems involved in it, plus focus on the sequential, predictable, stable, and
functional aspects of interactional behavior.
As mentioned in Chapters 9, 14, and l 6, it is
helpful for the therapist to have a support
system of other therapists and/or super‑ visors. Sometimes this can
be group or peer supervision, perhaps in the form of a team that
observes each other's session live. Or, it
might meet regularly
or periodically to view tapes or discuss clinical and case management issues, as did the group
described in Chapter 16. Not only can the group collaborate in designing
interventions, but it can also help to increase each member's
strength and leverage with
his own cases. For instance, a therapist who is
attempting to induce a crisis within a session is usually under
considerable counterpressure from the family to relent or back off. Having one
or more colleagues watching through a one-way mirror draws on the
greater pool of all their ideas, serves to spread the pressure among
them, and helps the therapist to hold more firmly to his position (see
Chapter 9). We would advocate that therapists working with
addicts' families take the steps necessary to form such a
support group whenever possible
OVERVIEW
OF SECTION II
The remaining chapters in this section present
some of the clinical material with which our therapy model has been
applied. The model provides them with a unifying or common thread.
The four case studies (Chapter 7, 9,
10, and 11) were selected for a number of reasons: (1) they all showed some
level of success; (2) they represent a cross-section of several
different kinds of cases (in regard to life cycle issues, ethnicity, etc.)
treated by therapists with varied credentials and styles; (3) they are
useful in making different points about the therapy; (4) the therapists
involved were interested in preparing them for publication; (5) for each
case we had complete, or near complete, videotape sets of 10 sessions, allowing the
material presented to be as complete as
necessary*; and (6) we had at least 3 years of posttreatment
follow-up information on each.
Chapter 7 presents a case that quite clearly depicts most of the features of the therapy model previously covered.
In addition, this family was chosen because it is so explicit. Not only do the
family members show the process and
patterns so frequently seen in other addicts'
families, but they verbalize
them as well (such as when the mother states in no uncertain terms that she does not want her son to
marry or to leave home). Other families may
give indications of similar
sympathies, but they may not verbalize them so unhesitatingly.
Chapter 8
discusses the importance of crises in bringing about change.
Rather than presenting a single case,
the authors survey crises across 39 cases and
the relationship between resolution of these crises
and treatment outcome.
Chapter 9 gives an example of crisis induction
in a case where the father (rather than the
mother) is the parent most indulgent of the addict. The therapist
forces the issue of the son's imminent death as a way of initiating
change.
Chapter 10 shows the intricacies of therapy with the
family of a drug pusher. Lengthy excerpts are presented from
the entire course of therapy.
examines therapy
with a family in which the parents have reached
retirement. A number of
conceptual points and general techniques are
also covered.
Chapter 12
presents the elements in a process—with accompany-ing clinical
material—for detoxifying the addict, in this case in the
family home. The home detoxification paradigm is
experimental we have
applied it with only a few cases—and permits a peek at the future direction of our work. This chapter also presents some excellent material on the necessary conditions and
procedures for the use of tasks in
family therapy.
Chapter 13 covers treatment strategies and techniques with families in which the drug
abuser is an adolescent. A number of
differences between these cases and families with
a young adult drug abuser are discussed. The therapy approach differs in some ways from
the model set forth in the present chapter, being
more structural and less strategic in
its thrust and operations.
Chapter 14 tunes us into a discussion among three of the clinical supervisors about some of
the issues and problems in this kind of
work. It deals with some aspects of the therapy
that have not received coverage
earlier in the volume.
Chapter 15 is a sister chapter to the present
one. It was felt that it would be premature to present this material
before exposing readers to the clinical matter in Chapters 7
through 14, from which
the material was derived. Chapter 15 also deals
with some matters of
controversy, discusses and contrasts case
examples, and extends the therapy
model to other populations.
